Dispatches From the Food Allergy Jungle

Hello. I know it's been a while since I've written. But it can be tough to get messages out from the Back of Food Allergy Beyond. The message traffic seems to only go one direction with food allergies. We feel very alone and isolated out here. But, I've been writing down our thoughts and experiences in a diary over the last few months, and will share some of those now with you.

From Day 14

Read today (after the fact) about another March food allergy death and saw a response from a noted allergist, someone I really respect. Her message was "why is it so hard to understand that FOOD ALLERGY KILLS?"

It almost broke me. I wondered again what we're doing out here, on the fringes, feeding our child these foods. We're off on this new tributary and there's just no support or shared experience on this particular river.

Does every allergy in every child really need to be treated the same? Where's the advice and support for outgrowing an allergy? For experimental treatments? Where is my village now? My tribe?

Day 26

We've learned the name of the river we're on by now: the Main Stream. It's been a little bumpy in places, but really we've been surprised at how smooth the sailing has been for the most part. We've been eating all sorts of strange, exotic foods. Plus, I'm cooking a lot now with ingredients that are really alien. There's this thin, white liquid that baby cows out here apparently eat. The indigenous people also whip it until it forms a solid. They put it in everything! However, we have only had it baked in the oven so far, and there seem to be new dangers in preparing this food in other ways.

There's another food that tastes a little strange at first, but is so ubiquitous that we've been happy to embrace it: soy. Our son has now eaten this soy (which can be found in the strangest places!) in various foods, including as a soy sauce glaze on things and even frozen Chinese treats from a trading post out here called "Trader Joe's." We have not tried the solid form of the food yet, not because we're afraid but because we all just agree it's too gross.

Day 33

As I mentioned, we don't get much mail out here on the Main Stream. But a newspaper article did reach us out here, simply because it must have caused a ton of ripples back where you all are: Parents Should Relax a Bit About Kids' Food Allergies.

I have to admit that I probably read this a little differently than most of you did, having learned about Toughing It Out here in the jungle. This idea of giving a child a little bit of a food to build tolerance would have been unthinkable to me before this trip. But now that I'm out here, dealing with treatments that feel like witch doctory, I'm no longer sure of where the right path is.

Day 50

We saw our allergist today! Our allergist has not been willing to tramp all the way out here and she's especially skeptical about the "natural treatments" we've been trying the last year, but she is willing to meet us half-way.

When I explained about the new foods we had been experiencing and my doubts about whether my son really needed to continue to avoid milk, she shook her head and pointed again to The Numbers. "But he's successfully eating so much and The Numbers have been all but meaningless in the past!" I exclaimed. She simply shook her head and pointed again at The Numbers. "Perhaps we'll reconsider in a year if The Numbers have fallen," she said.

She was excited to hear about our experiences with the soy substance, but she was unwilling to attribute it in any way to the natural treatment. We are not sure about anything at this point. Was she right and our son just reached some magical age/turning point, despite having had a hospital-trip reaction to soy just three years ago? Or did all those funny-smelling pills change something fundamental? All we can do is continue down the river and see where it leads.

Day 62

My son told me today he's no longer willing to wander off this path.

The topic came up because I've heard there are restaurants out here! Hundreds of them! We literally just need to go over the emotional hill to get to them. But my son is really nervous about the trip.

I can't say that I blame him. After all, he's the one who will be sick and suffer the consequences if it doesn't work out. But it just breaks my heart to be this close and yet know that he's not willing to go a few more steps. At the same time...I see the snakes.

Oh well. We all knew this journey would be difficult, and need to be taken in stages. We'll continue to explore the area we're already in. Perhaps when he's a little more accustomed to things, he'll be willing to take that next step. There will always be snakes...but we continue to remind him that he does carry powerful medication. But, of course, the story that lingers is the one about the snake-bitten child where the medicine didn't help.

Day 72

We came to the final fork in the road today and my son was forced to choose a direction. (The natives out here call the fork College Decision Day.) He had three options: two that would take him farther away from us and one that we could all see paralleled the current path. He went with the closer option. (The natives out here call it the Community College Path.)

The tribesmen were all very supportive and told him that they knew that path led to many other intersections down the way, and that he could stay on it for a year and then transfer to a different path with no difficulties at all. But his dad and I were a little sad. We wondered if he picked that road because of the difficulties we've encountered up until now.

The natives tell us we need to trust in the process and that all paths are good paths. I wish I could pour this awful fear out of my heart. I wish I could stop having expectations about this jungle and just live the life we've been given. I know it would be easier if there were others...but there do not seem to be. Our old friends think that what we're doing is crazy and dangerous; our new native friends do not understand our fears and hesitations.

I'll continue to write as much as I can. I know there are no guarantees the messages will reach you. But you're all I have on this journey: the few who understood why we left: the hope of finding a different, better place for our son to live.

I don't know if our path will turn out to be the right one, but we're too far down it to come back now.



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The Very Hungry Food-Allergic Caterpillar

My gangly teen caterpillar hatched out of his egg a l-o-n-g time ago. But he's still hungry!

On Monday, he ate through one muffin baked using real milk and butter.

On Tuesday, he ate through yeast coffee cake (butter, milk, yum!).

On Wednesday, he ate some of a Stouffer's spinach souffle.

On Thursday, he actually ate a store-bought Sara Lee pound cake. (Went back for seconds on that one!)

On FRIDAY, he ate...7 1/2 edamame.





OK, everything was not as straightforward as a children's book, but my son has been really pushing the limits of his baked-milk tolerance over the last couple of weeks (especially over spring break) to see just where he's at. The great news is that he's doing AMAZINGLY well tolerating everything we've been giving him.

Today (Friday) was his soybean food challenge, which he passed with flying colors! The grand total after two hours was 7 1/2 soybeans, with nary an itch, cough or stomach hiccup. (He's actually even back in school for his last class of the day.)

Best of all, his doctor agrees with our assessment that he's ready for a lot freer eating, including restaurant food. Since clearance for soy + baked milk = most bakery breads, that means he can have a hamburger or hot dog and French fries at just about any restaurant in town.

We have instructions to do no more soy today, to let him eat as much of the package tomorrow as he likes and then to gradually introduce soy into his diet without restriction. Our doctor also has no concern about doubling up on baked milk and soy, so that opens up a whole WORLD of processed frozen foods.

We talked through (again) the hazelnut issue. The RAST he just had done was a 2.0; the one from the clinical trial was around a 12. She wants to see one more negative SPT before believing it to be a pollen allergy and doing an outright challenge in the office. In the meantime, we're going to try green pea again and repeat scratch testing for milk, hazelnut and the rest of the beans. We're all of one mind at this point: knock off every allergen we can before college!

So...was it the FAHF-2? Hard to say. We know he was well along to outgrowing his soy allergy because his last soy reaction occurred after almost a full bowlful of soy ice cream about three years ago (I bought a look-alike product in soy instead of coconut by accident). He had a pretty serious reaction at that time that did involve trouble breathing, but it took a LOT of soy to generate it. We will be cautious, however, because it's still possible that there's a threshold above which he cannot tolerate soy and we just didn't get there today.

His doctor also indicated that it usually takes about a year of baked milk before they like to do an open challenge. That's not very long at all! I wish we had instituted baked milk about a decade ago, but hey - better late than never, right?

I'll report back as we get rolling on some of these new foods. (Chinese!)

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Easter Treats, Love, and Food Allergies

We're having a good Easter. My kids are now 18 and 14, but my 14-year-old daughter likes her traditions and still insists on the full basket-and-egg hunt, even while she's announcing she's really too old for all this.

My son has refused to hunt, or even to get out of bed the last couple of years, so this year my husband put the rest of their school-year allowance in the eggs. $10 an egg. Suddenly, he's in there fervently hunting. (They're down to their last couple apparently-unfindable eggs and are busy snarking at each other, so it's a good time to write a post.)

Easters past have been all about the...Legos? I will just admit it. Throughout my son's childhood, I simply inserted toys in any slot where candy was supposed to show up. A Lego for Easter. A Lego for a difficult trip to the doctor/dentist. Multiple Legos for Halloween. Secret Legos, slipped to him surreptitiously, while all the other kids are eating cake and ice cream. Over the years, our basement has turned into a Lego hoard that would make the builders at Legoland jealous.

I look back now and think why? Why did I invest so much money in redundant toys that really should have gone into his college fund?

And then I think about the cousin Easter baskets. Every year, the baskets would get handed out, and each child would sit down and fondle their chocolate wonders. The shiny wrappers! The giant bunnies! The enormous candy bars! And, in my son's basket: Lifesavers, Mike & Ikes, Airheads and Twizzlers.

The same candy at every party, every holiday, every lunch, every classroom treat.

By the time my son was in the late elementary years, he had learned not to care about the candy at all. It simply wasn't the important part of the party for him. If I had stood back and really looked, I might have seen that taking the food part of things away was actually helping him to enjoy and invest in the rest of the party in a more engaged way. My son loved parties and he loved people. He really didn't care about the cake. I did.

Food is love, after all, and the Lego was the best I could do to show my love in place of all those shiny, wrapped candy bars and Cadbury eggs and cheese-stuffed pizza and butter birthday cake with real cream ice cream.

Does different always = unequal? Does food always = love? Do we do our kids a favor by rushing into the gap with that Lego so they don't have to sort those equations out for themselves?

My son, despite my Lego-whenever-he-might-feel-left-out program, seems to have grown into a young man who can acknowledge, but not resent, the differences in his world. Yes, it's a PITA that he can't eat at his girlfriend's favorite restaurant...but what a testament to his character that they end up there often, anyway. Somehow, despite the Legos, he has learned it's not all about him.

That's something I'm very grateful for this Easter season. Sometimes they grow up well in spite of us.

Wishing you all a safe and very happy Easter!


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What-Causes-Food-Allergies March Madness!

It's time to fill in your bracket and take your shot! (And, with 3 million kids in the US alone, that's an awfully big pool!)

Vaccines! Always in the Top 8. Maybe it’s the peanut oil, even though peanut oil carries miniscule amounts of protein, even when it’s not highly purified. The timing is suspicious, too. After all, kids get allergy shots at the same time they’re developing allergies…

And the bracket winner is… GMO Foods!

GMO Foods! Another perennial contender. After all, shouldn’t a food cause a food allergy? The timing is suspicious (early 90’s introduction for many GMO foods).  And God knows Monsanto and other big Agra are sleazy…maybe to the point of not caring about our kids?

vs.

Tylenol! A surprise contender, as many parents trust the J&J brand more than Disney. However, acetaminophen has been implicated in other inflammation-linked disorders, including asthma and eczema.

And the bracket winner is… Tylenol!

Breastfeeding! Another entry in the category of "food causes food allergies" is breastfeeding. One recent study found a correlation between it and a higher rate of allergies. (Pediatricians, too!) But if that was all there was to the story, wouldn't every baby who breastfed become allergic? Does it make sense that Mother Nature would set up a system so maladaptive?

vs.

Hygiene Theory! The immune system gets...bored? Really? 100,000 years of human evolution and there's never been a time when the immune system had some down-time? O.k...

And the bracket winner is… Smoking, Obesity and/or High Salt Diets!

Smoking! Or Obesity! Or High Salt Diets! Or any other epigenetically-influencing environmental factor that's changed drastically between last generation and this one. Now you really can blame your parents for ruining your life.

vs.

Microbiome-Changing Chemicals Including Triclosan! Obviously a must-have choice for my own bracket, triclosan has both impressive research and a possible mechanism to explains food allergies going for it.  Will it go all the way this year?

And the bracket winner is… Microbiome-Changing Chemicals Including Triclosan!

Environmental Contaminants, include PAHs One of the hot topics at this year's AAAAI: can air pollution cause food allergies? Cigarette smoke is one source, but so are barbecue grills.

vs.

Global Warming! Or Sunscreen! Really! Changes in our atmosphere may be leading to changes in how children absorb Vitamin D.  Or, it may just be that this generation of parents has slathered on the sunscreen (with new chemicals in the 90s that do a better job of blocking rays).

And the bracket winner is… Global Warming! Or Sunscreen!

Infectious Disease! Maybe it's a virus! Specifically (according to some researchers) respiratory syncytial virus, or RSV. We know kids are wheezier after a bout of RSV...but does it really up the risk of sensitization?

vs.

Bad Landscaping! One interesting theory of how sensitization occurs is through exposure to pollen. So what's changed about pollen lately? Landscapers are using more and more plants that are not native to the areas in which they're being planted, resulting in exposure to new types of pollen.

And the bracket winner is… Money!

Money! Did you know that, the higher your income, the more likely your kid is to have a food allergy? Are richer kids simply diagnosed more? Or might it be the new carpets and new paint wealthier parents often introduce into the nursery before Baby is born?

vs.

Refrigerators!  Guess what? Bacteria evolve to adjust to new environments, and one of the harshest new environments we've provided to our bacteria is the refrigerator. Listeria and other bacteria have risen to the challenge, though, and many doctors now believe this "superbug" may be the cause of Crohn's and other intestinal disorders. Is food allergies one of them?

And the bracket winner is… Refrigerators!

Detection Bias! There are still some scientists who believe that this is really all about overdiagnosis. Their argument? They cite the 11% of the population of "sensitized" (allergic on a test only) to peanut vs. the 2-3% who actually demonstrate an allergy when fed peanut. More allergists = more testing = more false diagnoses.

vs.

Pesticides! Oh...and your tap water too. Dichlorophenols are just about everywhere! Oh, and guess what! There's plans to make a new genetically-modified corn bred to be resistant to them...so farmers can spray them all over our food. GREAT idea!

And the bracket winner is… A Dark Horse from Somewhere No One Has Ever Heard Of...

A Dark Horse from Somewhere No One Has Ever Heard Of... Maybe there's a scrappy little causative agent out there that has a lot of HEART and really wants to get in the GAME and TAKE this thing! YEAH!

Did you make your picks?

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The Not-Much-To-Update Update

I've waited to update you guys on my son's progress until I had some progress to report. I seem to be very unorganized and scatter-brained these days. True story: I called the allergist's office to get my son's RAST report.

ME: "Hi, I"m calling to see if you have my son's RAST test results back. It's been a couple of weeks since we were in."

NURSE: "Sure, let me check. Which lab did the blood draw?"

ME: "Um...what?"

NURSE: "We don't do blood draws here. Remember -- we gave you a lab order -- "

(She has to stop at this point because I've started laughing uncontrollably.)

NURSE: "Heidi? Is that you pimping me again? HEIDI?"

ME: "No, no, I'm sorry, I really am a parent. I just started laughing because I realized we never had the blood drawn. I'm so sorry!"

NURSE (long pause): "Um...o.k....I just thought it had to be the girl at the front desk again, teasing me. I mean, who calls for lab results when they haven't even - " (stops, as she realizes there's no way she can finish this sentence without letting me know what a complete IDIOT she thinks I am.)

ME: "Well, thanks! I'll obviously call back after we do the blood draw."

So that's how it's been going. My son did see his allergist and they did do SPT:

Milk	7/30 (about as bad as last time)
Soy	NOTHING!
Hazelnut	NOTHING!
Peanut	9/30

So...good and bad here. He's never had a completely non-reactive soy test. If the RAST comes back as promising, we'll probably do a soy challenge in the office in a month or two.

Hazelnut was an interesting conversation. The doctor agreed with my assessment that this is probably a pollen cross-reaction. She suggested an IOFC, rather than bothering with component testing, if the RAST is at a reasonable level.

Peanut was a shocker. If you remember, we actually had difficulty qualifying for the FAHF-2 food challenge because my son's RAST and SPT were borderline low for what they would accept. His peanut went from 3.5 during the challenge to a rather large 9 this time around. His allergist shrugged and said "well, you fed him peanut. That makes the numbers go up."

So does that mean he's more sensitized to peanut because the number went up? Honestly -- the more we've done RAST testing over the years, the more useless it's seemed to me. His RAST and SPT for green pea were (and still are) negative, and yet he failed that challenge, so clearly testing isn't everything.

Since the end of the clinical trial, we've introduced a ton of foods with "may contain" labels for both peanut and milk. (His allergist does concur with the advice from the clinical trial to start introducing these foods.) He's had absolutely no problem with any of it. For several weeks after the trial, we were also trying to work in daily baked milk. Again, he had no trouble with any amount we gave him, as long as it was straight milk or butter. However, over the last few weeks, we've all lost our mojo. I've recently started an in-office job (I've been freelancing from home the last year), so there's not a lot of time for baking and there's a very small window between a parent being home and it being too late in the evening to deal with the ER, should we need to do that.

I've actually toyed with the idea of sending his baked milk dose in his lunch. Our in-school nurse is very good and very interested in his clinical trial. I have a feeling she would be willing to be on-call if we wanted to risk doing this on her watch. But that seems a little far to go, even to speed up this process.

The bottom line is that I have a HUGE amount of empathy for the kids and parents in these OIT trials, where a daily dose is absolutely mandatory. My son missed at least two doses of FAHF-2 over the course of the trial. It was extraordinarily difficult to ensure every single dose was taken. (Granted: it was 3 doses a day, but even 1 dose every day is difficult.) If his desensitization had depended on my/his perfect compliance, we would have been in big trouble.

I also found that this new tolerance (and the potential to introduce soy in the near future) is causing issues I hadn't anticipated. A few days ago, we spent the day at one of the final two college possibilities. I spent about half an hour with food service trying to explain where he's at.

"So...if things go well, he may come to school with a lot fewer restrictions." The guy just looked at me and blinked. Clearly, they just want to know what to feed him and what not to feed him. This whole "maybe, sort-of, a little" business made both of us uneasy. How will he do baked milk at school, unless he's able to start eating it in everything?

I feel like we waited so long to try some of these things, and now we're out of time. I can quit my job again and dedicate myself to getting him as far as he's going to go with all this stuff. Or, I can work to pay for college. I apparently can't do both.

My son doesn't seem to have much interest in experimenting with milk-containing foods. He's definitely not an equal partner yet in pushing for new foods/higher tolerance. I think he just doesn't see his restrictions as that big a deal.

Who really needs to let go here?

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There's a Food Allergy Cure! Well, No, Maybe Not...

Haven't we all been here before?

There's a new professional cat fight in the food-allergy community this week, this one sparked by the New York Times story "Can A Radical New Treatment Save Children With Severe Allergies?"  (The NYT has a weird paywall thing going on where you only get to read so many stories a month, so hopefully the link will work for you.)

The therapy is new in that Dr. Nadeau has taken OIT therapy to the obvious next step and addressed all of a child's allergens at once, rather than the one-at-a-time approach that's not very helpful for those of us with MFA kids. Beyond that..not so much is new.

To give a little history, Dr. Nadeau first hit super-stardom at the 2011 AAAAI conference, where she presented a study of 11 milk-allergic kids who had been desensitized in a single day using Xolair®, a drug I just talked about in my Lord of the Rings manifesto that just about no one slogged through. To recap for all you readers who just hate fantasy, Xolair® inserts itself into the receptors in mast cells so IgE can't bind. It's like throwing a bucket of water on the overactive immune response. It also can cause cancer in some people...and anaphylaxis in a few...so not a drug for the faint-hearted.

As I noted in a post earlier this month during this year's AAAAI conference, the glow has faded from the OIT bloom. Here's how one conference follow-up  summarized the long-term outcome for milk OIT:

Only 25% could consume milk without symptoms at 3 months. More than half of the follow-up participants reported frequent symptoms accompanying milk consumption including six systemic reactions and two reactions requiring epinephrine. One participant, who was not symptomatic after passing a 16-gram challenge during the study, became reactive at follow-up and presently only consumes minimal milk.

"We're really worried that the [participants] will leave the study with a false sense of security," Wood said, adding that he'd seen participants lose protection in as early as 1 week off therapy. "Compounded with the fact that these kids don't like the foods they've been allergic to, there's a real inherent risk we need to recognize, and that risk actually scares me a lot more than the recognizable short-term risk" which patients face with monitored dose-escalation, he said. Wood noted that oral immunotherapy "is not yet ready for clinical practice," and that more research is needed with longer follow-up.

There's no reason (yet!) to think the addition of Xolair® to this process will change the outcome. So...just as the New York Times is hitting the street with a sensational headline, the long-term outcome for this therapy has never been more in doubt. 

I still remember the last time the media grabbed the "food allergy cure" headline and ran with it: after the OIT trials first started in North Carolina. Not a week went by for several months without someone coming up to me with a printout showing that "they had cured food allergies" if I presumably would just get on my giddy-up and check it out. My brother sent me the link. Our neighbor. A co-worker. God love them for remembering my child has a food allergy, and for caring enough to send me the information...but it was almost felt like blame that we just were not trying hard enough to cure him.

Another doctor, Wayne Shreffler from Mass. General, has obviously been here before as well. He issued a letter addressing his concerns about the NYT feature.

And then it got weird. The author of the NYT article, Melanie Thernstrom, rebutted Dr. Shreffler's rebuttal.

Can we hope for a rebuttal of a rebuttal of a rebuttal next? Meow!

But seriously...I see both sides of this thing. I am so tired of hearing about the magical cure that's just around the corner, especially when I've been on the yo-yo of hope with this therapy for several year. We KNOW some kids will outgrow their allergy if they're force-fed their allergen. But we're also finding out that it doesn't work at ALL for other kids, and for a third group, it works at first and then fails...sometimes dismally. One in three odds (or thereabouts) is not really a cure, especially if the 1/3^rd of kids it works on would have outgrown their allergies anyway. If this therapy only targets the outgrowers, then it's not really a therapy at all -- just a shortcut.

On the other hand...one in three. Why not? I can see where parents would throw the dice, in the hope their kid would be one of the lucky ones. If you are that dice-throwing parent, there are going to be a series of new clinical trials opening up around the country that utilize Xolair® as part of the OIT process.

My son and I actually discussed whether he wanted to participate in this trial because Chicago will be one of the sites. However, we all have clinical trial exhaustion at this point. We also picked FAHF-2 for a reason: because it had great potential for positive outcome without the "rebound allergy" that seems to be happening with kids in some of these other trials.

I don't like to be a Nervous Nelly. But, before I would sign up for this trial, I'd want an honest answer from the researchers involved as to why they think Xolair® plus oral immunotherapy has the potential to succeed where just plain oral immunotherapy has not. Haven't we been here before?

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How Do Food Allergy Treatments Work?

I've been thinking a lot lately about whether our experience with the FAHF-2 food allergy trial was worth all the time and hassle. In a sense, the jury is still out because we don't know yet what effect the medication may have had on my son's milk allergy. (The near impossibility of getting an almost 18-year-old to stay still in one place while consuming baked milk is a topic for another blog post.) However, I also grapple with what exactly the medication did.

So why is there a creepy Orc over there, you ask? Because it seems to me that, up until this point, food allergy treatments have used a Lord of the Rings strategy. Think of the cast of characters this way:

The allergen is the Orc. Maybe he's completely misunderstood, but bad things seem to occur as soon as he hits the kingdom so, as soon as they see even one Orc, the  mast cells go all nutty and light the signal fires. This starts a cascade of chemical messages throughout the body.

Histamines and other chemical messengers play the part of the Riders of Rohan. They see the fires and go forth to every cell in the body and say "rally the troops!"  Antihistamines work by coating cell receptors so the Riders of Rohan simply can't get inside the cell to deliver the message. That's why there's a lot of debate about whether putting out some of those signal fires can help to lessen reactions.

However, doctors don't recommend antihistamine only to treat reactions for an important reason: neither the number of Orcs or the number of Riders of Rohan determine the allergic response. It's what happens next that determines just hives...or full-out anaphylaxis...or something in-between.

Whether a few riders make it through or a lot of them do, at some point, the body decides how forcefully it's going to respond. For most people, the response seems to be dose-dependent: the more Orcs in the body, the more Riders of Rohan, the more forceful the response.

However, for a sub-segment of allergic individuals, the response is way out of proportion to the threat. If the right few Orcs show up...or the right Riders reach the king...a severe response/reaction can occur. There are a couple of theories as to why. One theory is that some people have a genetic variant that causes their body to over-respond to perceived threats. Another theory is that children who are allergic to more than one hot spot on a protein are likely to have a more robust response.

Once the King and all his troops are called to the body's battlefield, it's hard to stop the war. Epinephrine is the best way. Like the Ents in the river scene in "The Two Towers", epinephrine opens up closed airways and sweeps away chemical messengers that have caused so much trouble. It also gets fluids to return to the river bed instead of running rampant through the body once all the fun is over.

So how does all this relate to the food allergy clinical trials currently underway? In almost all of these trials (oral immunotherapy, SLIT, skin patch), the idea is to just keep slipping Orcs into the body until the Riders of Rohan get used to them. After all, there are only so many times you can pelt into the hall of the king and shout "Rally the troops!" before the king stops listening.

However, these studies all seem to have an upper limit. While the Riders will ignore a few Orcs, eventually a tipping point is reached where the body can no longer ignore the incursions. That's the difference between desensitization (getting used to a few Orcs) and tolerance (no longer seeing Orcs as a threat at all). Plus, most of these studies seem to depend on having those Orcs constantly milling about. If you take the Orcs away for a few weeks and then reintroduce them, the signal fires get lit and the riders ride, just as if they were never there at all. That's why kids who miss a day of oral therapy can suddenly find themselves having a bad reaction. Is living with Orcs really the best option?

The newest therapy on the horizon is OIT combined with omalizumab (Xolair®), a drug that works at the very beginning of the process by inserting itself into the receptors in mast cells so IgE can't bind. If you think of the Orc and the signal fire, omalizumab acts like rain on the fire wood. The signal fire never gets started, so the Riders of Rohan never ride and...well, you get the idea.

The problem with this is that omalizumab also seems to get in the way of the immune system recognizing and fighting cancer cells. It can also work in the complete opposite way and cause anaphylaxis for some people. That's why it comes with what's known as a "black box" warning -- a strong caution that only people who really don't have another choice should consider using the drug. However, the people conducting these food-allergy studies believe that the very small amount of time the drug will be used will not cause any long-term immune effects.

The theory is that one day, the body will wake up after therapy and see Orcs everywhere. Since there were no signal fires and no Riders of Rohan, the armies of Middle Earth will (in theory) just shrug and go "hey, guess those Orcs weren't so bad after all."

Yeah, doesn't seem like it would work to me either. But that's the theory. Some kids just seemed destined to learn to live with Orcs, so this may just be accelerating the process for those kids. For others, it may just be a faster way to learn that they're not good candidates for OIT. Only time will tell if it's all just a fantasy.

So what happens with FAHF-2?

That seems to be a different story altogether. Rather than training the body to ignore an allergen through desensitization, the medication seems to cause a general snooziness in the immune system. Poppies...poppies.

How does it work? No one knows. Somewhere along the Yellow Brick Road, something changes. FAHF-2 works for all allergens and it works whether those allergens are in the body or not, so it's a very different model than OIT. Perhaps it reduces overall inflammation. Perhaps it promotes an environment where something missing (gut bacteria?) can get re-established. Whatever the mechanism, it does not seem to have the same overall suppressive effect on the immune system that omalizumab does.

The truth with all this is that, despite long flowcharts of chemical mediators attached to most research studies, no one really knows the answer to the important question: what causes an allergy in the first place? Why does the Wicked Witch of the Allergic West tell some children "I'll get you, my pretty" and ignore other kids altogether? What bucket of water will destroy all that beautiful wickedness?

Somewhere out there is the magic formula that will cause these allergies to just melt away. Maybe we all just need to click our ruby slippers together a little harder.


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